role of high resolution computerized tomography chest in identifying tubercular etiology in patients diagnosed as eales disease

Kharel (Sitaula) et al Journal of Ophthalmic Inflammation and Infection (2017) 7:4 DOI 10.1186/s12348-016-0120-1 Journal of Ophthalmic Inflammation and Infection ORIGINAL RESEARCH Open Access Role of high-resolution computerized tomography chest in identifying tubercular etiology in patients diagnosed as Eales’ disease Ranju Kharel (Sitaula)1, Vandana Iyer2, Veena Noronha4, Parthopratim Dutta Majumder3 and Jyotirmay Biswas5* Abstract Background: The high resolution computerized tomography of chest is an important diagnostic imaging tool to identify any pulmonary tubercular lesion It's role in Eales' disease to identify any possible association with pulomonary tuberculosis has not been studied earlier So, this study was conducted to assess the role of high resolution computerized tomography (HRCT) chest in identifying tuberculous etiology in Eales' disease Results: It was a retrospective study conducted at a tertiary care eye hospital in South India between January 2009 and October 2014 were included A total of 29 diagnosed cases of Eales' (24 male and female) were included in the study These patients were followed up for a mean period of 739.75 days Out of them, 13 (44.8%) had bilateral and 16 (55.2%) had unilateral ocular involvement Eight cases (34.5%) patients had vitreous inflammation Mantoux test was positive in 12 (41.4%) cases and chest x-ray suggestive of TB was present in four cases (13.8%) QuantiFERON TB gold was positive in 15 (51.7%) and HRCT chest suggestive of TB was positive in 15 (51.7%) case Out of 15 Eales' cases with positive HRCT scan suggestive of TB, the commonly noted lesions were calcified nodules 34.5%, mediastinal hilar lymphadenopathy 13.8%, parenchymal soft tissue lesions in 3.4% Five (17.2%) cases underwent pars plana vitrectomy for non resolving vitreous hemorrhage and one case underwent retinal attachment surgery with encirclage Six patients were started on months regimen of ATT by the chest physician Final visual outcome improved in 17(40.5%) eyes, maintained in 21(50%) eyes but vision deterioration in 7(16.7%) eyes Conclusions: HRCT chest is an important diagnostic tool to rule out pulmonary tuberculosis in Eales’ disease Keywords: HRCT chest, Eales’ disease, Vasculitis, Tuberculosis Background Eales' disease is an idiopathic inflammatory venous occlusion of the peripheral retina of young adults It is characterized by periphlebitis, peripheral capillary nonperfusion, and neovascularizations [1, 2] The most common presentation is bilateral recurrent vitreous hemorrhage and its sequelae [3] Eales' disease is usually a diagnosis of exclusion [4] Several systemic diseases * Correspondence: drjb@snmail.org Director of Uvea and Ocular Pathology, Medical and Vision Research Foundations, Sankara Nethralaya, 18- College Road, 600006 Chennai, India Full list of author information is available at the end of the article have been thought to be associated with its occurrence but none of the associations have been proven The association of Mycobacterium tuberculosis as a causative agent in Eales' is still not well understood Cell mediated immunity against tubercular antigen was reported to be associated with Eales' disease [5] Polymerase chain reaction (PCR) studies on vitreous sample and epiretinal membrane of Eales' disease patients have confirmed the presence of Mycobacterium genome [6, 7] Confirmation of tubercular cause in a case of Eales' disease helps in starting evidence based and target oriented therapy for © The Author(s) 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made Kharel (Sitaula) et al Journal of Ophthalmic Inflammation and Infection (2017) 7:4 Eales' disease thereby leading to a better resolution of the disease and less number of recurrences HRCT chest is an efficient non-invasive diagnostic tool which can differentiate between active and inactive form of tuberculosis (TB), can identify post primary TB, and can demonstrate pulmonary cavity lesions, endobronchial lesions and mediastinal hilar lymphadenopathy [8] It is also of immense help in differentiation of similar granulomatous conditions The use of HRCT chest for the detection of tuberculosis in Eales' disease has not been studied so far In this study, we evaluated the utility of HRCT chest for the detection of tubercular lesions in lungs of Eales' patients in a TB-endemic country like India Methods This study was a 5-year retrospective hospital-based analysis of patients of Eales' disease presenting to a tertiary care eye hospital in south India, between January 2009 and October 2014 All patients with clinical diagnosis of Eales' disease were included in the study Eales' disease was diagnosed based on the features of midperipheral retinal periphlebitis, peripheral capillary non-perfusion, neovascularizations, and recurrent vitreous hemorrhage in healthy young males in the absence of any other possible systemic association [5] Detailed ocular examination was performed Fundus fluorescein angiogram (FFA) was done in all cases to rule out capillary non-perfusion area and neovascularization at disc and elsewhere The staging was done using new staging system for idiopathic retinal periphlebitis as Page of described by Saxena and Kumar [9] Tuberculin skin test with five PPD, serum angiotensin enzyme levels, vasculitis work-up, chest X-ray, QuantiFERON TB Gold test, and HRCT chest were done For the HRCT chest, images of 1-mm thickness were taken at 30 mm spacing from lung apices to lung bases, at the end of full inspiration All the scans were studied for lung parenchyma, mediastinum, pleura, and chest wall A high-resolution (bone) algorithm was used for image reconstruction The plain HRCT was routinely performed, and contrast scan was done as per requirement Single radiologist by a single blinding technique recorded the pattern of chest findings, analyzed and grouped into four groups according to the classification by Ganesh et al [10] The decision for antitubercular treatment (ATT) was taken by a chest physician after correlating the clinical findings with HRCT The patients with at least 2-year follow-up were included in the analysis and recurrences during this period analysed Approval from the ethical committee of the institution was taken, and adherence to the tenets of Declaration of Helsinki was maintained Statistical analysis was performed using Statistical software (SPSS 14) Confidence intervals of 95% was taken, and p value